ADHD COMORBIDITY AND DIFFERENTIAL DIAGNOSIS...ADHD vs DEPRESSION ADHD •Inattentiveness,...
Transcript of ADHD COMORBIDITY AND DIFFERENTIAL DIAGNOSIS...ADHD vs DEPRESSION ADHD •Inattentiveness,...
ADHDCOMORBIDITY AND
DIFFERENTIAL DIAGNOSIS
DR. MANOJ BHATAWDEKAR
INATTENTION (CALL FOR FrEd)• Careless mistakes
• Attention difficulty
• Listening problem
• Loses things
• Fails to finish what he/ she starts
• Organisational skills lacking
• Reluctance to do tasks that require a sustained mental effort
• Forgetful in routine activities
• Easily distracted
HYPERACTIVITY- IMPULSIVITY(RUNS FASTT)
• Runs or is restless
• Unable to wait for his or her turn
• Not able to play quietly
• Slow?- oh no! On the go!
• Fidgets with hands or feet
• Answers are blurted out
• Staying seated is difficult
• Talks excessively
• Tends to interrupt
"Diagnostic criteria" is not just a list of "symptoms" as narrated by the patient/ relatives.
It is the clinical impression formed after listening to the symptoms and observing signs.
Previously they were just called children!!
Stephen Hinshaw Ph.D.
Case 1
• A 10 year old boy is found to be restless in the class
• Not attentive
• Appears not to participate in any activities
• Seems to be lost in his own thoughts, daydreaming
• Answers in monosyllables
• Work incomplete
• When questioned or confronted breaks down into tears
• Not interested in play activities
• Not eating well
• Lost weight
• Disturbed sleep
• All these symptoms started at a point in time
ADHD vs DEPRESSION
ADHD
• Inattentiveness, distractibility, losing things
• Failure to finish tasks or activities, reluctance to start if needs sustained mental effort
• Difficulty organizing
DEPRESSION
• Impairment of concentration and memory, preoccupation with mood
• Fatigue, anergia, loss of interest
• Anergia, cognitive impairment
ADHD vs DEPRESSION
ADHD
• Hyperactivity , fidgeting, restlessness
• Excessive talking
• Impulsive blurting of answers
• Restless sleep
• Irritability
DEPRESSION
• Agitation
• Agitated, complaining
• Preoccupied with complaining
• Insomnia
• Irritability
DISTINGUISHING FEATURES OF DEPRESSION
Depressed mood, anorexia, weight loss, suicidal ideation, guilt feelings, psychomotor slowing, mutism, fatigue
Case 2
• A 14 year old girl seems to be very hyperactive in the class
• Not sitting at one place
• Very talkative
• Disturbs others
• Does not obey instructions
• Often leaves her classroom
• Laughs a lot
• Often irritable, especially if her activities are thwarted
• Wants to do too many things
• Fights a lot with her peers
• Started at a point in time
ADHD vs BIPOLAR (MANIA)
ADHD
• Inattentiveness, distractibility, forgetfulness, losing things
• Failure to finish tasks, reluctance to start if needs sustained mental effort
• Difficulty organizing
• Hyperactivity, fidgeting, restlessness
BIPOLAR (MANIA)
• Flight of ideas, thought racing, distraction by grandiosity
• Flight of ideas, grandiosely above common tasks
• Flightiness
• Psychomotor acceleration, driven quality
ADHD vs BIPOLAR (MANIA)
ADHD
• Excessive talking
• Impulsive blurting of answers, interrupting, intruding
• Impatience, easy frustration, difficulty waiting
• Irritability
• Restless sleep
BIPOLAR (MANIA)
• Pressured speech
• Pressured speech, flight of ideas, impulsive poor judgment
• Pressured hyperactivity and impulsiveness
• Irritability, labile affect
• Decreased need for sleep
DISTINGUISHING FEATURES OF BIPOLAR MANIA
Extreme driven quality, sometimes episodic, prominent mood, irritable, grandiose, possible appetite change and weight change, family history of mood disorder
Case 3
• An 8 year old boy is found to be restless in the classroom
• His work is incomplete
• He tries to answer every question that is asked by the teacher
• He does not want to take part in sports
• He is scared to go to the playground
• He tries to please his teachers by 'over obedient' behaviour
• He is scared of getting low grades in the exams
• He wants to visit the toilet very often
• He wants to cling to his classteacher
• He very often cries while coming to school
ADHD vs ANXIETY INCLUDING PTSD
ADHD
• Inattentiveness, distractibility, forgetfulness, losing things, careless mistakes
• Failure to finish tasks, reluctance to start if needs sustained mental effort
• Hyperactivity, fidgeting, restlessness, on the go
ANXIETY INCLUDING PTSD
• Preoccupation with worry, intrusive memories, flashbacks, psychic numbing, hypervigilance
• Fear- induced paralysis of function, afraid to try, expecting failure, avoiding reminders
• Panic, agitation, anxiety-driven restlessness, nervousness
ADHD vs ANXIETY INCLUDING PTSD
ADHD
• Excessive talking
• Impulsive blurting of answers, interrupting, intruding
• Impatience, easy frustration, difficulty waiting
• Restless sleep
• Emotional and physiological instability
ANXIETY INCLUDING PTSD
• Anxious verbosity, obsessions, verbal rituals
• Anxious eagerness, reenactments
• Intolerance of delay that builds suspense or reminds of trauma
• Insomnia, nightmares
• Nervousness, physiological instability
DISTINGUISHING FEATURES OF ANXIETY INCLUDING PTSD FROM
ADHD
Phobias, worries, stress- induced onset, obsessions and compulsions, perfectionism, tremor, physiological symptoms, posttraumatic play
Case 4
• A 15 year old boy is found to be daydreaming
• Not attentive in the class
• Does not participate in activities
• Grades have fallen remarkably
• Reluctant to write
• Refuses to answer when asked a question
• Often found to be muttering to self
• Withdrawn
• Has expressed suspiciousness about his friends
• Does not communicate properly
• Gets into fights when provoked
• All these symptoms started at a point in time
ADHD vs PSYCHOSIS
ADHD
• Inattentiveness, distractibility, losing things, careless mistakes, forgetfulness
• Failure to finish tasks, reluctance to start if needs sustained mental effort
• Difficulty organizing
• Hyperactivity, fidgeting, restlessness, on the go
PSYCHOSIS
• Withdrawal from reality, preoccupation, loose association, distraction by hallucinations
• As above, abrupt change of activity
• Psychotic fragmentation
• Psychotic agitation, response to hallucinations
ADHD vs PSYCHOSIS
ADHD
• Excessive talking
• Impulsive blurting of answers, interrupting, intruding
• Impatience, easy frustration, difficulty waiting
• Irritability
• Insomnia
• Lability, instability
PSYCHOSIS
• Talking to hallucinations
• Responding to hallucinations
• Lack of social orientation
• Paranoid irritability
• Insomnia
• Unpredictability, lability
DISTINGUISHING FEATURES OF PSYCHOSIS
Delusions, poverty of thought, inappropriate affect, command hallucinations
Case 5
• A 9 year old boy is found to be inattentive in the class
• He does not follow instructions
• Seems to be lost in himself
• Gets irritable at times
• Does not communicate much in the class
• Has stereotyped movements of hands
• Unable to relate with others in social situations
• Motor clumsiness
• Obsessive insistence on sameness
ADHD vs PDD
ADHD
• Inattentiveness, distractibility, losing things, careless mistakes, forgetfulness
• Failure to finish tasks, reluctance to start if needs sustained mental effort
• Hyperactivity, fidgeting, restlessness, on the go
PDD
• Disregard of people, decreased responsiveness to attempted communication
• Abrupt change of activity, resistance to instructed activity, adherence to preferred activity
• Hyperactivity, twirling, pacing, flapping
ADHD vs PDD
ADHD
• Excessive talking
• Impulsive blurting of answers, interrupting, intruding
• Impatience, easy frustration, difficulty waiting
• Irritability
• Insomnia
• Lability, instability
PDD
• Compulsive stereotyped repetitions
• Obliviousness of personal space of others
• Easy frustration
• Tantrum when routine is interrupted
• Insomnia
• Lability, unpredictbility
DISTINGUISHING FEATURES OF PDD FROM ADHD
Impaired nonverbal/ verbal communication, lack of social relatedness, fantasy or social or imaginative play
PSYCHOSOCIAL CONDITIONS
• Abuse or neglect
• Poor nutrition
• Neighbourhood violence
• Chaotic family situation
• Being bullied at school
MEDICAL DISORDERS
• Partial deafness or poor eyesight
• Seizure disorder
• Fetal alcohol syndrome
• Genetic abnormalities (e.g. Fragile X syndrome)
• Sedating or activating medications
• Thyroid abnormalities
• Heavy metal poisoning
ADHD plus OPPOSITIONAL DEFIANT DISORDER
• 3- 6 years of age - 52.3%
• 7- 10 years of age - 31%
ADHD plus LEARNING DISORDERS
between 25- 40 %
ADHD plus CONDUCT DISORDER
7- 10 years of age - 14%
ADHD plus TIC DISORDER
7- 10 years of age- 11%
ADHD plus COMMUNICATION DISORDERS
3- 6 years of age- 21.9%
KEY POINTS IN DIAGNOSIS
• Clinical diagnosis based on interviews and rating scales
• No specific laboratory test
• A full psychiatric evaluation
• No role for 'therapeutic trials' with stimulants
• Family history, medical problems, substance abuse
• Talking to school personnel
KEY POINTS IN DIAGNOSIS
• Observing the child in the clinical setting may not be conclusive
• Observations in school most useful
• Rating scales for parents and teachers
REFERENCES
• Child and Adolescent Psychiatry - Dorothy Stubbe
• Rutter's Textbook of Child and Adolescent Psychiatry
• Child Psychopathology- Eric Mash
• Taking Charge of ADHD- Russell Barkley
• Driven to Distraction- Edward Hallowell